Parent Child Therapy Clinic
Web Inquiry Form
Preferred Language:
*
English
Spanish
Parent / Guardian Name
*
Parent/Guardian's First Name
Parent/Guardian's Last Name
Parent or Guardian Phone Number
*
Parent or Guardian Email Address
*
example@example.com
What type of therapy services are you seeking?
*
Individual Therapy for my child
PCIT Services for my child
Parenting Services for myself
Child's Name, for child services
Child's First Name
Child's Last Name
Child's Date of Birth, for child services
/
Month
/
Day
Year
Please select your PRIMARY reason for seeking therapy for your child. If seeking parenting services, please select "Parenting Services for Myself" choice below:
*
ADHD
Anger
Anxiety
Behavioral Issues
Death/Loss of a Loved one
Depression
Divorce/Separation
Emotion Management
Family Conflict
Parenting Services for myself
PCIT
School Conflict
Trauma
Other Reason for child services
Who Referred You to Our Clinic / How did you hear about us?
*
Carelon/Beacon Referral
Care Solace Referral
Current Client
Doctor Referral
Doctor Lee Referral
Facebook
Friend or Relative Referral
Insurance Company
Internet Search
Mandalay Bay Clinic Referral
I was a Past Client
A Past Client Referred me
PCTC Employee Referral
Pediatric Diagnostic Clinic (PDC)
Previously on Waitlist
Psychology Today
Other Therapist Referral
School Referral
Sibling of Current Client
Social Worker
Surfside Pediatric Clinic
PCTC Website
VCBH County Referral
Voice Mail / Phone Call
Other
Please Select Your Primary Insurance Provider:
*
Aetna
Anthem Blue Cross
Blue Shield of California
Cash Pay Option
Cigna
Gold Coast Insurance
Kaiser Permanente
Medicare
Tricare
United Health Care
UMR
VCHP (Ventura County Health Plan)
Other
Do you have Secondary Insurance:
*
Yes
No
Will you be a Cash Pay client:
*
Yes
No
Are you open to TeleHealth appointments, if necessary?
*
Yes
No
Maybe
Are you related to or personally know anyone at our clinic:
*
Yes
No
If you answered 'Yes', who are you related to or personally know?
0/200
Comments or Additional Info:
By providing your phone number, you agree to receive text messages from Parent Child Therapy Clinic regarding your intake process. Message and data rates may apply. Message frequency varies.
*
I Agree
Submit
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